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201 0 Miracle on Ice Conference© Minneapolis Heart Institute® at Abbott Northwestern Hospital
First Steps in ResuscitationField to Emergency Department
Graham Nichol MD MPH
Medic One Foundation Endowed Chair in Prehospital Emergency Care
Director University of Washington Center for PrehospitalDirector, University of Washington‐Center for PrehospitalEmergency Care
Medical Director, University of Washington Clinical Trial Center
University of Washington, Seattle, WA
Disclosures• NHLBI, Bethesda, MD; Co‐PI, Resuscitation Outcomes Consortium Data
Coordinating Center.• NHLBI Bethesda MD PI Randomized Trial of Hemofiltration After• NHLBI, Bethesda, MD; PI, Randomized Trial of Hemofiltration After
Resuscitation from Cardiac Arrest.• NHLBI, Bethesda, MD; Co‐I, Randomized Field Trial of Cold Saline IV After
Resuscitation from Cardiac Arrest.• Asmund S. Laerdal Foundation for Acute Medicine Stavanger, NO; PI,
Randomized Trial of CPR Training Aid in Community.• Medtronic Foundation, Minneapolis, MN; PI, Cascade HeartRescue
Program.• Sotera Wireless, San Diego, CA; Research Collaborator.• Gambro Renal Inc., Denver, CO; Research Collaborator.• Lifebridge North America Inc., San Antonio, TX; Research Collaborator.• American Heart Association, Dallas, TX; Travel Expenses.
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What Is A Cardiac Resuscitation System of Care?
SystemMeadows Thinking in Systems 2008
• Interconnected set of elements that is h tl i d i t hicoherently organized in a way to achieve
something.
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Cardiac Resuscitation System of CareNichol Circulation 2010
• Interconnected community, EMS and hospital t t f h it l di t th tresponse to out‐of‐hospital cardiac arrest that
is coherently organized to improve processes and outcome in a region.
Leading Causes of Death in U.SExtrapolated from Nichol JAMA 2008 and www.cdc.gov
Other Cardiac Causes
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Disorder
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EMS‐Assessed Cardiac ArrestNichol JAMA 2008
Alabama(n=715)
Dallas(n=2,462)
Iowa(n=1,028)
Ottawa(n=2,965)
Pittsburgh(n=1,217)
Portland(n=1,320)
Seattle and KC
(n=2,349)
Toronto(n=5,155)
Vancouver (n=2,373)
Overall(n=19,584)
I id 106 7 159 0 93 1 71 8 105 1 77 5 144 0 96 8 75 9 95 0Incidence,per 100,000
106.7 159.0 93.1 71.8 105.1 77.5 144.0 96.8 75.9 95.0
Survival, % 1.1 2.4 6.1 3.3 3.3 6.5 8.1 3.2 6.7 4.4
Missing VS, %
2.0 1.5 1.2 0.7 0.3 1.5 0.1 0.4 1.2 0.8
Ventricular FibrillationNichol JAMA 2008
Alabama(n=267)
Dallas(n=1,265)
Iowa(n=565)
Milwaukee
(n=801)
Ottawa(n=1,836)
Pittsburgh(n=575)
Portland(n=793)
Seattle and KC
(n=1,170)
Toronto(n=2,992)
Vancouver (n=1,634)
Overall(n=11898)
Incidence 9 9 12 8 12 4 18 7 10 4 9 3 15 1 19 0 11 4 15 2 12 8Incidence,per 100,000
9.9 12.8 12.4 18.7 10.4 9.3 15.1 19.0 11.4 15.2 12.8
Survival, % 7.7 9.5 22.7 26.0 14.8 21.5 22.5 39.9 15.7 25.0 21.0
Missing VS, %
3.1 7.9 4.4 0 2.1 1.0 3.6 0.3 1.3 3.3 2.5
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Survival from Admission to One Month
Herlitz Resuscitation 2006
Survival After OOHCA Over TimeSasson Circ Cardiovasc Qual Outcomes 2010
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• Out‐of‐hospital cardiac arrest is major public h lth blhealth problem.
• Large variation in survival.• Treatable condition.• Outcomes have not improved in many communities over timecommunities over time.
Wake County, NCHinchey Ann Emerg Med 2010
• Multiphase before‐after study– BaselineBaseline
• CPR with C:V ratio 15:2• Stacked shocks
– “New” CPR• Early intubation deemphasized• Minimal interruption in compressions• Defibrillation with single rather than stacked shocksC l f il i• Control of ventilation rates
• Intraosseous vascular access– Impedance threshold device– Field hypothermia
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Wake County, NC Hinchey Ann Emerg Med 2010
Patient Volume vs. Outcome for Cardiac ArrestCallaway Annals of Emerg Med 2010
Annual Volume of Patients Received
Number of Hospitals
Survival to Discharge (%)
Adjusted Odds of Death (95% CI)
1‐9 103 28.7 Reference
10‐19 55 30.8 0.85 (0.65, 1.12)
20‐29 23 32.6 0.89 (0.65, 1.21)
30‐39 11 28.3 1.04 (0.75, 1.45)
> 40 11 37.3 0.91 (0.67, 1.25)
Adjusted for patient factors (witnessed collapse, initial rhythm, and age) and hospital factors (cath capability)
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AUTHOR
STUDY DESIGN
POPULATION INTERVENTION COMPARATOR ALTERNATIVE COMPARATOR
Vermeer
I di id l d i d
AMI, presenting at hospitals not capable of PPCI
Transfer for PPCI (n=75)
Symptoms to therapy
Fibrinolytic in non‐PCI hospital (n=75)Symptoms to therapy
Fibrinolytic with transfer; rescue PCI if indicated (n=74)
Randomized Trials of Regionalized STEMI CareAdapted from Nichol Circulation 2010
Individual randomized trial in 1 province, Netherlands
240 + NRDoor to balloon NRDeatha 7%Recurrent infarcta 1%Strokea 3%
135 + NRDoor to balloon NRDeatha 7%Recurrent infarcta 9%Strokea3%
Symptoms to therapy255 + NRDoor to balloon NRDeatha 8%Recurrent infarcta 5%Strokea 4%
Widimsky
Individual randomized trial in 1 province, Czech Republic
AMI, presenting within 6 h of symptom onset at hospitals not capable of PPCI
Immediate transfer for PPCI (n=101)
Symptoms to therapy215 + NRDoor to balloon NRDeathb 7%Recurrent infarctb 1%
Fibrinolytic therapy in non‐PCI hospitals (n=99)
Symptoms to therapy132 + NRDoor to balloon NRDeathb 14%Recurrent infarctb 10%
Fibrinolytic therapy during transport for PCI(n=100)Symptom to therapy220 + NRDoor to balloon NRDeathb 12%Recurrent infarctb 7%Recurrent infarct 1%
Strokeb 0%Recurrent infarct 10%Strokeb 1%
Recurrent infarct 7%Strokeb 3%
Andersen
Individual randomized trial in Denmark
AMI with ST elevation presenting at hospital not capable of PPCI
Transfer for angioplasty within 3 h (n=567) Symptoms to therapy227+NRDoor to balloon 26Deathb 7%Recurrent infarctb 2% Strokeb 2%
Fibrinolysis at referral hospital (n=562) Symptoms to therapy150+NRDoor to therapy NRDeathb 9%Recurrent infarctb 6% Strokeb 2%
N/A
AUTHOR
STUDY DESIGN
POPULATION INTERVENTION COMPARATOR ALTERNATIVE COMPARATOR
Grines
Individual randomized trial in US and Europe
High‐risk AMI with ST elevation or presumed new left bundle branch block <12h
Transfer for PPCI (n=71) Symptoms to therapy NRDoor to balloon 174 + 80Deathb 8%
Fibrinolytic therapy (n=66) Symptoms to therapy NRDoor to therapy 63 + 39Deathb 12%
N/A
Randomized Trials of Regionalized STEMI Care (continued)
in US and Europe Recurrent infarctb 1% Strokeb 0%
Recurrent infarctb 0% Strokeb 4%
Bonnefoy
Individual randomized trial in France
Patients with STEMI presenting to EMS within 6 h of symptom onset
Primary PCI (n=421)Symptoms to therapy NRDeathb 5%Recurrent infarctb 2%Strokeb 0%
Prehospital fibrinolysis(n=419)Symptoms to therapy NR Deathb 4%Recurrent infarctb 4%Strokeb 1%
N/A
Widimsky
Individual randomized trial in Czech Republic
Patients with STEMI within 12 h of symptom onset presenting to non–PCI‐capable hospital
Immediate transfer for primary PCI (n=429)Symptoms to therapy203 + NRDeathb 7%Recurrent infarctb 1%St k b 0%
Fibrinolytic in community hospital (n=421)Symptoms to therapy185 + NRDeathb 10%Recurrent infarctb 3%St k b 2%
N/A
Strokeb 0% Strokeb 2%
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Trauma Systems of CareNathens JAMA 2001
h
Trauma Systems of CareNathens JAMA 2000
ed Relative Odd
s of D
eath
Adjuste
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• Direct and indirect evidence that regional di it ti t f illcardiac resuscitation systems of care will
improve outcome• Effects
– Take time to develop– Depend on patient volumeDepend on patient volume
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How Can We Improve Field Care for Out‐of‐Hospital Cardiac Arrest?
Improve Manual CPR!
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Chest Compression Fraction During First CPR by EMS
Christenson Circulation 2009
EMS CPR Before Rhythm AnalysisCobb JAMA 1999
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EMS CPR Before Rhythm AnalysisWik JAMA 2003
EMS CPR Before Rhythm AnalysisBradley Resuscitation 2010
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EMS CPR Before Rhythm AnalysisBradley Resuscitation 2010
Preshock PauseEdelson Resuscitation 2008
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Preshock PauseEdelson Resuscitation 2008
Compression DepthEdelson Resuscitation 2008
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Chest Compression RateAbella Circulation 2005
Use Single Rather than Stacked Shocks!
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Shock to Perfusing RhythmSunde Resuscitation 1999
• Observational study of out‐of‐hospital cardiac arrest in Norway (n=156 patients, 883 shocks).
• Pulse generating rhythm regardless of duration after shock: • 90 shocks (10%) in 51 patients had any ROSC;• 35 (4%) had sustained ROSC after shock;
• 14 after first shock• 2 after second shock • 3 after third
Single versus Stacked ShockRea Circulation 2006
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Single versus Stacked ShockRea Circulation 2006
Ignore Manual Compression Devices!
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Mechanical Compressions Using Load‐Distributing Band Device
Ong JAMA 2006
Of 210 patients in whom LDB device was applied,38 patients (18.1%) survived to hospital admission (95% CI 13.4%, 23.9%)12 patients (5.7%) survived to hospital discharge (95% CI, 3.0%, 9.3%).
Mechanical Compressions Using Load‐Distributing Band Device
Hallstrom JAMA 2006
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Mechanical Compressions Using Load‐Distributing Band Device
Hallstrom JAMA 2006
Consider Continuous Chest Compressions?
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Minimally Interrupted Cardiac Resuscitation by EMS
Bobrow JAMA 2008
Continuous compressions, passive or positive pressure ventilation early use of epinephrinepressure ventilation, early use of epinephrine,
deferred use of advanced airway
Minimally Interrupted Cardiac Resuscitation by EMS
Bobrow Ann Emerg Med 2009
Outcomes PV (n459) BVM (n560) Adjusted OR (95% CI)n/N (%) n/N (%)
ROSC 123/459 (26.8) 169/560 (30.2) 0.8 (0.7, 1.0)
Adjusted neurologically intact 46/459 (10.0) 53/560 (9.5) 1.2 (0.8, 1.9)survival to hospitaldischarge
Adjusted neurologically intact 39/102 (38.2) 31/120 (25.8) 2.5 (1.3, 4.6)survival with witnessedVF/VT
Adjusted neurologically intact 3/41 (7.3) 8/58 (13.8) 0.5 (0.2, 1.6)survival with VF/VT, notwitnessed
Adjusted neurologically intact 4/316 (1.3) 14/381 (3.7) 0.3 (0.1, 1.0)survival with nonshockablerhythm
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Ignore Intravenous Drugs!
Intravenous DrugsOlasveengen JAMA 2009
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ITD or not ITD? That is the question.
Impedance Threshold Device
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Aortic‐to‐right atrial pressure gradient during relaxation phase of cardiopulmonary resuscitation
Coronary Perfusion PressureParadis JAMA 1990
Impedance Threshold Device ImprovesCoronary Perfusion Pressure
Aufderheide Crit Care Med 2005
ry P
erfu
sion
Pre
ssur
e (m
mH
g)
STD (n=11)
5
10
15
20
* P<002
** * * * * * * * *
Microsphere
ITV (n=11)
Cor
ona
06 8 10 12 14 16
P<0.02Injected
Minutes
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Use of ITD Associated with Better Outcomes for Patients with PEA at any time during
Resuscitation in Milwaukee TrialAufderheide Crit Care Med 2005
P t h b
No significant difference btwnCPR and CPR+ITD
Post hoc subgroup analysissusceptible to bias
when adjustedfor multiple comparisons
Effect Observed in Blinded vs. Unblinded Trials
Bero PLOS Medicine 2007
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Shiny Object Syndrome
• National Geographic studied a group of monkeys. • Local tribe would trap monkeys by putting bright shinyLocal tribe would trap monkeys by putting bright shiny objects in small holes in trees, making sure monkeys saw them doing it.
• Tribesmen watched from a distance as monkeys would reach into trees to retrieve bright shiny objects.
• With their hands clenched around shiny object, they could not pull hands out of tree.
• Monkeys were so intent on hanging onto bright shiny objects that they would not let go, even when tribesmen would approach and slip bags over heads of monkeys.
Shiny Object Syndrome (2)
• Whatever real priority is in the moment, i.e., that thing I really want to get done has pressurething I really want to get done, has pressure attached to it.
• It has to be good or right. • Faced with an unconscious decision between working on this thing that has to be exactly right (e.g. CPR) or something that's marginally effective but that I will not judge myself about (e.g. ITD).
• My ego chooses for me.
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Wake County, NC Hinchey Ann Emerg Med 2010
Western Electric Company, Hawthorne Plant, Chicago, IL
Series of studies conducted in the 1920s by Shewhart: worker productivity increased during observation.
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Consider Limiting Oxygenation?
Pilot Randomized Trial of 30% vs. 100% Oxygen After Resuscitation
Kuisma et al Resuscitation 2006
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Quasi Randomized Trial of Oxygen Supplementation in Patients with Stroke
Rønning Stroke 1999
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No animals were harmed during the preparation of this talk.
Epinephrine + Vasopressin vs. Epinephrine Alone
Gueugniaud N Engl J Med 2008
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Amiodarone vs. LidocaineDorian N Engl J Med 2002
Amiodarone vs. LidocaineDorian N Engl J Med 2002
42%
Statistically significant benefit from treatment across all groups (overall p= 0.009)
23%
12%
25%
14%12%
4%
27%
20%
11%
4%
Amiodarone vs. PlaceboKudenchuk N Engl J Med 1999